The Relationship of Philosophies, Models, and Theories
The philosophies, models, and theories of a discipline are theoretical structures that address the central concepts of that discipline. The science of nursing is rec-ognized as a fundamental pattern of knowing for nurses (Carper, 1978). Fawcett (2005) proposes a nursing metaparadigm based on Kuhn’s (1970) philosophy of science and paradigm development. The metaparadigm specifies disciplinary boundaries of human beings, environment, health, and nursing as a context to understand the interrelationships among those elements of contemporary nursing science (Fawcett, 2005).
Theoretical knowledge may be differentiated by the way it is named or labeled. A model tends to be named for the person who authors it, for exam-ple, the Neuman Systems Model. Grand theories tend to be named for the out-come they propose, for example, the Theory of Optimal Client System Stability, and theories tend to be named for the characteristics their content demarcates as an explanatory shell of the outcomes they propose. An example is Gig-liotti’s (2003) theory of women’s multiple role stress, which she validated as middle range with the age groups of women and forms of stress (Gigliotti, 2011, 2012).
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Table 3-1 presents types of nursing knowledge at each level of abstraction and an example of nursing knowledge for each type.
• The metaparadigm is the most abstract set of central concepts for the discipline of nursing (i.e., human being, environment, health, nursing), and these concepts are defined within each of the conceptual models and according to the philosophy of that model.
• Philosophies present the general meaning of nursing and nursing phe-nomena through reasoning and logical presentation of ideas (Alligood, 2005). Although Nightingale (1946) did not present her philosophy on the relationship of patients and their surroundings as a theory, her phi-losophy contains implicit theory that guides nursing practice.
• Conceptual models (also called paradigms or frameworks) such as the Neuman Systems Model (Neuman & Fawcett, 2011) are the next less abstract set of concepts in the structure.
• Grand theory (e.g., Neuman’s Theory of Optimal Client System Stabil-ity) is next as the level of abstraction descends. Theory can be consid-ered grand when it is nearly as abstract as the model itself and when the usefulness of the model depends on the soundness of that theory. Grand theory is especially useful in research and practice because it is more general, and theories specifying the details of practice can be derived from it.
• Theory is the next less abstract level; it is more specific than grand theory but not as specific as middle-range theory (e.g., Optimal Client System Stability in specific settings).
• Finally, as mentioned earlier, middle-range theory is the least abstract set of concepts and the most specific to nursing practice (e.g., promoting Optimal Client System Stability through a stress reduction intervention in the work environment). The understanding of theory terminology is developed over time with knowledge of works at the different levels of abstraction (Fawcett, 2005; Reynolds, 1971).
TABLE 3-1 A Structure of Nursing Knowledge Types and an Example of Each Type
Knowledge Type Examples of Types of Nursing Knowledge Metaparadigm Human beings, environment, health, nursing Philosophy Nightingale’s philosophy
Conceptual models Neuman Systems Model Grand theory Optimal Client System Stability
Theory Flexible line of defense moderates Optimal Client System Stability Middle-range theory Flexible line of defense moderates stress levels for Optimal Client System
Stability in women who are enacting multiple roles (Gigliotti, 2011) Knowledge types based on Fawcett, J. (2005). Contemporary nursing knowledge: Conceptual models and theories (2nd ed.). Philadelphia: F. A. Davis.
Philosophies are theoretical works that address one or more of the metapara-digm concepts (person, environment, health, and nursing) in a broad philosophical way. Philosophies address questions such as:
• What is nursing?
• What is the nature of human caring?
• What is the nature of nursing practice?
• What is the social purpose of nursing? (Alligood, 2005).
Therefore, philosophies are broad statements of values and beliefs that propose general ideas about what nursing is, what nursing’s concerns are, and how the pro-fession addresses its moral obligation to society. Each philosophy is a unique view of nursing.
Nursing models are frameworks or paradigms of the science of nursing that address the person, environment, health, and nursing metaparadigm. What this means in terms of nursing practice is that the way you think about people and about nursing has a direct effect on your approach with people, what questions you ask, how you process the information that is learned, and what nursing activities are included in your care. Therefore, a model provides a perspective of the person for whom you are caring, specifies the focus for the delivery of care, and structures the reasoning, critical thinking, and decision making in your practice.
Nursing theories derive from models and are guiding structures for reasoning and decision making about the person, the person’s health situation, and the care indicated. Theories are composed of sets of concepts, but they are less broad and propose specific outcomes. Theories may have been derived from a philosophy, a nursing model, a more abstract nursing theory, or a model or framework from another discipline. Theories are based on propositions or relationship statements that are consistent with theoretical works from which they are derived, but a theory coming from a nursing model such as Theory of Accelerating Change (based on Rogers’ Science of Unitary Human Beings) or Theory of the Person as an Adap-tive System (based on Roy’s Adaptation Model) is more focused and guides your approach and perspective. When you approach people from the perspective of a certain nursing theory and ask questions, process information, and carry out spe-cific activities, an outcome is anticipated based on the theory. This is true whether the theory is guiding the design and delivery of nursing care or the design and conduct of a research project. Just as theory strengthens nursing practice, theory-based research produces evidence for practice (Fawcett, 2012a,b). Theories have been specified as important forms of evidence. Evidence-based nursing practice is encouraged but is dependent on ways to recognize quality evidence. And the quality of evidence-based practice is dependent on recognition of quality research (Fawcett & Garity, 2009).
Middle-range theory is the least abstract in the structure of knowledge and as the term range suggests middle-range theories are at various levels of abstrac-tion. These theories are at the practice level, and include details of nursing practice.
Grand Theories such as Rogers’ Theory of Accelerating Change, Roy’s Theory of the Person as an Adaptive System, and Neuman’s Theory of Optimal Client System Stability are examples of grand theories because they are broad and their level of abstraction is close to the model from which they are derived. When a theory is at
44 PART 1 Conceptualization
the grand theory level, many middle-range applications of that theory can be devel-oped for practice by specifying factors such as:
• The situation or health condition • The client population or age group
• The location or area of nursing practice (e.g., home, hospital, community)
• The action of the nurse or nursing intervention
The process of specifying the details in the theory makes it less abstract and less broad; therefore, it applies to specific types of patients, in specific situations, and proposes specific outcomes about the care for the patient. Research reports of studies that test middle-range theories and specify the details yield findings that are evidence for evidence-based practice.
In this theory utilization era the communities of scholars surrounding nursing theoretical works (philosophies, models, and theories) continue to grow and expand globally (Bond, Eshah, Bani-Khaled, et al., 2011; Im & Chang, 2012). Growth in the development and use of middle-range theory in research and practice has exploded in the global nursing literature. Expansion is obvious by publications in scholarly nursing books and journals. A few recent examples are Bultemeier (2012) in Malawi and the long history of Neuman’s Systems Model in Holland (Merks, Verberk, Kuiper, et al., 2012). Nursing theory societies have global members who contribute ideas for mid-dle-range theory development, testing, and use in theory-based practice (Biggs, 2008;
Bond, et al., 2011; Daiski, 2000; Dobratz, 2008; Dunn, 2005; Fawcett & Garity, 2009;
Frey, Sieloff, & Norris, 2002; Gigliotti, 2012; Im & Chang, 2012; Sieloff & Frey, 2007).
Discussion of these types of nursing theoretical works follows, and the appli-cation chapters in Part II (Chapters 5 through 20) of this text illustrate nursing practice with each type.